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BUREAU OF MINES 
INFORMATION CIRCULAR/1989 

C 366- 

IZI 




Cleaning, Disinfecting, and Sterilizing 
Self-Contained Self-Rescuer 
Mouthpiece Assemblies Used in 
Hands-On Training 

By Michael J. Brnich, Jr. and Henry J. Kellner, Jr. 



UNITED STATES DEPARTMENT OF THE INTERIOR 



Mission: As the Nation's principal conservation 
agency, the Department of the Interior has respon- 
sibility for most of our nationally-owned public 
lands and natural and cultural resources. This 
includes fostering wise use of our land and water 
resources, protecting our fish and wildlife, pre- 
serving the environmental and cultural values of 
our national parks and historical places, and pro- 
viding for the enjoyment of life through outdoor 
recreation. The Department assesses our energy 
and mineral resources and works to assure that 
their development is in the best interests of all 
our people. The Department also promotes the 
goals of the Take Pride in America campaign by 
encouraging stewardship and citizen responsibil- 
ity forthe public lands and promoting citizen par- 
ticipation in their care. The Department also has 
a major responsibility for American Indian reser- 
vation communities and for people who live in 
Island Territories under U.S. Administration. 



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T^fiwW*^. 



Information Circular 9236 

/! 



Cleaning, Disinfecting, and Sterilizing 
Self-Contained Self-Rescuer 
Mouthpiece Assemblies Used in 
Hands-On Training 

By Michael J. Brnich, Jr. and Henry J. Kellner, Jr. 



UNITED STATES DEPARTMENT OF THE INTERIOR 
Manuel Lujan, Jr., Secretary 

BUREAU OF MINES 
T S Ary, Director 






e <}(, 



Library of Congress Cataloging in Publication Data: 



Brnich, M. J. 

Cleaning, disinfecting, and sterilizing self-contained self-rescuer mouthpiece 
assemblies used in hands-on training / by Michael J. Brnich and Henry J. Kcllncr, 
Jr. 

p. cm. - (Bureau of Mines information circular) 

Includes bibliographical references. 

1. Self-contained self-rescuer (Mine rescue equipment)-Safety measures. 2. 
Communicable diseases-Prevention. I. Kellner, H. J. II. Title. III. Series: 
Information circular (United States. Bureau of Mines); 9236 

TN295.U4 [TN297] 622 s-dc20 [614.4'8] 89-600276 

CIP 



CONTENTS 

Page 

Abstract 1 

Introduction 2 

Background 2 

Sterilization 4 

Disinfection and cleaning 4 

Dental profession 4 

Cardiopulmonary resuscitation training 4 

Scuba training 5 

Methods used in mining 5 

Self-contained self-rescuer mouthpiece testing 6 

Discussion 6 

Conclusions 6 

References 7 

TABLE 

1. Guide to chemical agents for disinfection and/or sterilization 3 



UNIT OF MEASURE ABBREVIATIONS USED IN THIS REPORT 

°F degree Fahrenheit mL milliliter 

gal gallon min minute 

h hour ppm part per million 

Hz hertz 






CLEANING, DISINFECTING, AND STERILIZING 
SELF-CONTAINED SELF-RESCUER MOUTHPIECE ASSEMBLIES 

USED IN HANDS-ON TRAINING 



By Michael J. Brnich, Jr. 1 and Henry J. Kellner, Jr.' 



ABSTRACT 

This U.S. Bureau of Mines report addresses issues involved in using a limited number of training 
apparatus to give hands-on self-contained self-rescuer (SCSR) training to a succession of miners, and 
provides guidance regarding methods for minimizing the spread of infectious diseases. Procedures used 
for preventing the spread of infectious organisms in dentistry, cardiopulmonary resuscitation (CPR) 
training, and scuba training are examined. The sanitizing methods of three organizations that require 
individuals to insert the mouthpiece as part of the SCSR donning sequence are discussed. It was found 
that each of these organizations was able to render their mouthpiece assemblies microbe free simply and 
inexpensively. 



Mining engineer. 
Industrial engineering technician. 
Pittsburgh Research Center, U.S. Bureau of Mines, Pittsburgh, PA. 



INTRODUCTION 



In June 1987, the Mine Safety and Health Administra- 
tion (MSHA) issued an Emergency Temporary Standard 
(ETS) requiring hands-on SCSR training for all persons 
entering underground mines (I). 3 The ETS specifies four 
elements that must be included in SCSR training. These 
are as follows: (1) Opening the device; (2) activating the 
oxygen; (3) inserting the mouthpiece or simulating this task 
while explaining the procedure; and (4) putting on the 
noseclips. 

Studies of miners putting on the SCSR indicate that the 
failure to obtain a good seal on the mouthpiece is a fairly 
common error, which can be remedied and corrected 
through additional hands-on practice (2). Simulation of 
this task obviously provides no feedback, thus leaving in 
doubt the trainee's ability to complete this critical task 
during an actual mine emergency. Therefore, many mine 



trainers adopt a training strategy that includes insertion of 
the mouthpiece. This permits the practice of the entire 
sequence including breathing through the SCSR training 
apparatus. 

The use of a single training apparatus to provide hands- 
on training for several miners presents a problem. There 
are widespread concerns over the spread of infectious 
organisms such as hepatitis B, herpes, and acquired im- 
mune deficiency syndrome (AIDS). Mine trainers seek 
methods for protecting miners as well as themselves from 
contracting these diseases during SCSR training. These 
concerns parallel similar expressions by individuals working 
in the medical and dental communities. This U.S. Bureau 
of Mines report explores the issues involved and provides 
guidance regarding the use of methods for minimizing the 
spread of infectious diseases during hands-on practice. 



BACKGROUND 



The terms sterilization, disinfection, and cleaning have 
different definitions, but quite often these terms are mis- 
used and interchanged. Sterilization is defined as the use 
of some form of chemical or physical method to destroy all 
microbial life, including highly resistant bacterial endo- 
spores (3). In effect, a sterilized object will remain sterile 
as long as it is kept in a sterile environment. Obviously, 
the process of sterilizing is more complex than disinfecting. 
Disinfection is defined as a process that inactivates nearly 
all pathogenic micro-organisms, but not all microbial forms 
(bacterial endospores) on inanimate objects (3). All other 
treatments come under the category known as cleaning 
which, in itself, can be useful. Table 1 provides a listing of 
chemical agents used in disinfection and/or sterilization; a 
chemical classification for these agents; and corresponding 
disinfectant and/or sterilant characteristics. 

Many mine trainers have their trainees demonstrate the 
motor task of mouthpiece insertion. Consequently, a few 
mouthpiece assemblies may be used by many individuals 
in hands-on SCSR training. Therefore, it was decided that 
the researchers should review methods for preventing the 
spread of infectious organisms in other settings in which 
objects that contact mucus membranes of the body are 
used to serve the needs of many people. Techniques used 
for abating the spread of infectious organisms in dentistry, 



Italic numbers in parentheses refer to items in the list of references 
at the end of this report. 



CPR training, and scuba diving were assessed to determine 
the feasibility of using these techniques in hands-on SCSR 
training. 

Methods for preventing the transmission of infectious 
diseases in the dental profession have been reviewed in 
earlier studies (4-5). Information currently available for 
the dental profession discusses modes of transmission of 
infectious diseases. The information also reviews methods 
for prevention of transmission of such diseases including 
the use of sterilization, disinfection, and thorough cleaning 
of instruments, equipment, and work areas. Research 
focusing on disease transmission in CPR training was 
examined (6-7). The information reviewed discusses tech- 
niques that reduce the possibility of disease transmission. 
These methods include the use of protective equipment 
(face shields or masks) by trainees, simulation of rescue 
breathing in two-rescuer CPR training to reduce manikin 
contact, and procedures for decontaminating manikins 
once they are used. 

Finally, research addressing the topic of disinfection 
procedures for scuba equipment was reviewed (8). Al- 
though there are a number of diving training and certifi- 
cation agencies in addition to equipment manufacturers, 
the literature indicates there are no standardized recom- 
mendations for decontamination of shared scuba equip- 
ment. However, the literature does discuss methods that 
can be used for adequate cleaning and disinfection of 
shared scuba equipment used in training and rental 
settings. 



Table 1. -Guide to chemical agents for disinfection and/or sterilization 



Accepted 
products 



Chemical 
classification 



Disinfectant 



Sterilant 



ProMed brand 

Wescodyne-D 

Biocide. 
Household 

bleach. 
Dentaseptic 

Multicide 

Omni II. 
Sporicidin . . . 



Glutarex 



Banicide 
Sterall 
Wavicide 01. 



Exspor 



Centra^ 
Cidex 7 



lodophors, 1% 
available iodine. 

Sodium hypochlorite. 

o-phenylphenol, 9% and 
o-benzyl-p-chlorophenol, 

Glutaraldehyde 2% 

alkaline with 

phenolic buffer. 
Glutaraldehyde 2% 

neutral. 

Glutaraldehyde 2% 
acidic potentiated 
with nonionic 
ethoxylates of 
linear alchohols 

Chlorine dioxide 



1%. 



Glutaraldehyde 2% 
alkaline. 



Diluted according 

to manufacturer's 

instructions, 30 min. 
Diluted 1:5 to 1:100,* 

10 to 30 min. 
Diluted 1:32, 

10 min at room 

temperature. 
Diluted 1:16, 

10 min at room 

temperature. 
Full strength, 

10 min at room 

temperature. 
Diluted 1:2, 

10 min at room 

temperature. 



2 min at room 
temperature. 

Full strength, 
10 min at room 
temperature. 



NAp 

NAp 
NAp 



Full strength, 
6-3/4 h at room 
temperature. 

Full strength, 
10 h at room 
temperature. 

Full strength, 
1 h at 140° F 
4 h at 104° 
to 122° F, 10 h 
at room 
temperature. 

6 h at room 
temperature. 

Full strength, 
10 h at room 
temperature. 



NAp Not applicable. 

! Ratio used bleach to water. 

Available in regular (14-day activity) or long life (28-day activity). 



STERILIZATION 



Several types of sterilization procedures are employed 
in the dental profession to sterilize instruments and equip- 
ment used. These techniques include hot sterilization 
using steam or dry heat, gas sterilization, and chemical 
cold sterilization. Sterilization is not used in CPR training, 
nor is it advocated for use with scuba diving equipment. 

Hot sterilization involves the use of pressurized steam 
in a steam autoclave or the application of dry heat. For 
proper sterilization to occur, the temperature inside the 



steam autoclave must be from 250° to 270° F. When dry 
heat sterilization is used, temperatures must range from 
340° F for 1 h to 250° F for 16 h. For gas sterilization, 
instruments are placed in ethylene oxide gas sterilizers. 
For gas systems, special piping and other provisions in- 
cluding venting to the outside are required because the 
gas is toxic. Cold sterilization uses liquid chemicals and is 
employed for heat-sensitive instruments or objects. 



DISINFECTION AND CLEANING 



Several methods are employed for conducting disinfec- 
tion cleaning in the dental profession, CPR training, scuba 
training, and in annual refresher SCSR training for miners. 
Methods for disinfection include high-level disinfection 
using disinfectant-sterilant chemicals registered by the U.S. 
Environmental Protection Agency (EPA) or boiling water 
and disinfection using chemical germicide solutions. Sev- 
eral methods are available for cleaning dental instruments 
and other objects. These methods include thorough wash- 
ing and ultrasonic cleaning. Ultrasonic cleaning is a tech- 
nique in which objects are immersed in a liquid cleaning 
medium that is aided by ultrasonic waves (waves greater 
than 16,000 Hz) generated by the cleaning vessel. 

DENTAL PROFESSION 

High-level disinfection can be accomplished by immer- 
sion in either boiling water for at least 10 min or an EPA- 
registered disinfectant-sterilant chemical for the exposure 
time recommended by the chemical's manufacturer. Disin- 
fection can also be done with suitable chemical germicides. 
For disinfection of work areas in dentistry, a solution of 
sodium hypochlorite (household bleach) prepared fresh 
daily is recommended as an inexpensive and effective 
germicide. Bleach-water concentrations that range from 
5,000 to 500 ppm (1:10 to 1:100 dilution of bleach) are 
effective, depending on the amount of organic material on 
the surface to be cleaned and disinfected. 

Before disinfection or sterilization of instruments can 
take place, they must be thoroughly cleaned to remove 
blood, saliva, and other substances that are present. 
Cleaning can be accomplished in several ways. First, one 
can clean by thoroughly scrubbing instruments with soap 



and water or a detergent. All adherent debris must be 
removed, the instruments thoroughly rinsed, and then 
dried. Cleaning can also be accomplished by using me- 
chanical devices such as ultrasonic cleaners. 

CARDIOPULMONARY RESUSCITATION 
TRAINING 

In 1983, an ad hoc committee for evaluating sanitary 
practices in CPR training was formed and developed rec- 
ommendations for decontaminating manikins used in CPR 
training. The committee was comprised of representatives 
from the American Heart Association, the American Red 
Cross, and the Centers for Disease Control. The com- 
mittee recommended that CPR manikins be disassembled, 
thoroughly washed, and rinsed. Following washing, all 
surfaces capable of disease transmission are to be wet for 
10 min with a sodium hypochlorite solution containing at 
least 500 ppm free available chlorine (1/4 cup household 
bleach per gallon of tap water). Following use of the 
bleach and water solution, the parts are to be rinsed thor- 
oughly with tap water and dried. This bleach solution 
must be made fresh for each CPR class and discarded 
after use. 

Cleaning standards for CPR manikins closely follow 
those advocated for the dental profession. CPR instructors 
are advised to disassemble the manikins according to the 
manufacturer's directions. The components are to then be 
thoroughly washed with warm soapy water. The manikin 
parts are to be scrubbed with a brush to remove all saliva 
and other substances. Once washed, the parts can be 
rinsed with tap water and allowed to air-dry. 



In 1985, inquiries began to increase regarding the ade- 
quacy of the standards recommended for manikin decon- 
tamination in killing the AIDS viral agent. Subsequent 
studies revealed that the viral agent causing AIDS, human 
T-cell lymphotropic virus type III-lymphadenopathy- 
associated virus (HTLV-III-LAV), is delicate and is inac- 
tivated at room temperature in less than 10 min by a num- 
ber of disinfectant chemical solutions including sodium 
hypochlorite. 

The bleach dilution, used in conjunction with thorough 
scrubbing and rinsing, will ensure that the HTLV-III-LAV 
virus and a variety of other infectious agents will be killed. 
The literature indicates that if the recommended decon- 
tamination procedures are followed consistently in CPR 
training, students will use manikins that have a sanitary 
quality equal to or better than that of eating utensils found 
in restaurants. 

SCUBA TRAINING 

In scuba training and scuba equipment rental, the use 
of shared equipment is common. As mentioned earlier, 
literature indicates that there are no formal standards for 
decontaminating shared scuba equipment. It is known that 
in certified, nationally recognized diving courses, training 
is required to be conducted with special diving equipment 
having a second regulator-mouthpiece and hose assembly 
attached to the primary air tank regulator. With this type 
of equipment, each diver will have his or her own mouth- 
piece during training. As a result, the risks of disease 
transmission are reduced. 

The Centers for Disease Control have made some 
recommendations for decontaminating scuba mouthpieces. 
These recommendations include thorough cleaning of the 
devices followed by disinfection. Disinfection can be ac- 
complished by immersing the mouthpiece in some broad- 
spectrum germicidal solution. Exposure to a fresh solution 
of household bleach (1/4 cup bleach in 1 gal of tap water) 
for 10 min is considered sufficient for disinfection. Fol- 
lowing disinfection, the mouthpieces can be rinsed with 
fresh tap water and permitted to air-dry. 

Manufacturers of scuba equipment have recommended 
that devices be rinsed thoroughly with fresh tap water. 
For shared equipment, it is recommended that the mouth- 
pieces be removed from the unit and thoroughly scrubbed 
with soap and warm water. Brushes should be used to 
scrub away substances found on the surfaces of the 
mouthpiece and to adequately scrub the breathing hoses. 



Following scrubbing, the mouthpieces can be rinsed with 
fresh tap water and permitted to air-dry. 

METHODS USED IN MINING 

The cleaning procedures used by three mining organi- 
zations in preventing the spread of infectious diseases 
during SCSR training are described below. These three 
organizations are providing a method of hands-on training 
that requires individuals to insert the mouthpiece as part 
of the training sequence. 

Organization A: Since July 1986, Organization A has 
been involved in hands-on SCSR training for its personnel 
using three Draeger 4 OXY-SR 60B training apparatus 
modified to permit quick changeout of mouthpiece as- 
semblies. Twenty additional mouthpieces were purchased, 
permitting a clean assembly to be installed before each 
use. Following use, the mouthpiece assemblies were re- 
moved, scrubbed in soap and water, and rinsed. Following 
rinsing, the assemblies were then soaked overnight in a 
chemical sterilant solution known as Cidex 7. The assem- 
blies were then removed from the sterilant solution, thor- 
oughly rinsed with water, and permitted to air-dry. 

Organization B: Trainers purchased 27 extra mouth- 
piece assemblies for use with 6 to 12 CSE AU-9A1 train- 
ing models. Used assemblies are removed, cleaned, and 
then disinfected by soaking in a household bleach-water 
solution for 30 to 45 min. Trainers mix the bleach-water 
solution at a ratio of approximately 1 part bleach to 
10 parts warm water (5,000 ppm bleach solution). After 
soaking, the mouthpiece assemblies are rinsed with warm 
water and are allowed to air-dry. 

Organization C: This organization chose to purchase 
mouthpiece assemblies for each of the employees receiving 
hands-on training at their operation. Nearly 100 Draeger 
OXY-SR 60B assemblies were bought and each was en- 
graved with a serial number to identify the worker who 
used it. After use, the assemblies were cleaned in a soap- 
water solution and then packaged each in a separate plas- 
tic storage bag. The mouthpieces were not disinfected or 
sterilized in any form. Trainers maintain the mouthpiece 
assemblies for reuse during followup evaluations. The 
organization felt that with this program, it could ensure 
each miner that an individual would use only his or her 
own mouthpiece. 

Reference to specific products does not imply endorsement by the 
U.S. Bureau of Mines. 



SELF-CONTAINED SELF-RESCUER MOUTHPIECE TESTING 



In early 1988, the Bureau obtained a random sample of 
four mouthpiece assemblies from organization A, four 
from organization B, and five from organization C. As 
mentioned earlier, organization A used a chemical cold 
sterilant for mouthpiece assemblies and organization B 
used a bleach-water solution to disinfect. Organization C 
cleaned their assemblies with a soap and water solution. 

An independent biological testing laboratory conducted 
tests for micro-organisms on each mouthpiece assembly. 
Two major tests were conducted. The first was a standard 
plate count, which is a broad-spectrum bacteria test. The 



second was an anaerobic plate count for determining the 
presence of organisms that grow in oxygen-free environ- 
ments. Test results indicated that, for each mouthpiece 
tested, a count of fewer than 100 organisms per milliliter 
of sterile water was observed for both types of plate 
counts. For drinking water, the legal safe limit for micro- 
organisms is 500 per milliliter of sterile water. These 
results indicate that each mouthpiece tested was free of 
micro-organisms, regardless of which cleaning-disinfecting- 
sterilizing method was used. 



DISCUSSION 



The methods for cleaning and disinfecting SCSR 
mouthpiece-hose assemblies reviewed in this report are 
procedures currently used by trainers. Other methods may 
be practiced. For example, organization A originally 
rinsed used mouthpieces with water, immersed the assem- 
blies in rubbing alcohol (70% alcohol) for several minutes, 
and then permitted them to air-dry. Many trainees com- 
plained of the foul taste of alcohol left on the mouthpiece 
after cleaning, however. Later, this organization switched 
to rinsing the mouthpieces and soaking them in a soap 
solution. Following immersion in the soap and water 
solution, the mouthpieces were rinsed thoroughly with 



water and permitted to air-dry. Finally, the trainers began 
using the Cidex 7 solution discussed above. 

In August 1987, Bureau personnel investigated the 
possibility of using hot (steam) sterilization for sanitizing 
SCSR mouthpieces. Several Draeger mouthpiece assem- 
blies were placed into a steam autoclave in an attempt to 
sterilize them. When the mouthpieces were removed from 
the autoclave, major deformation of the plastic parts of the 
assemblies was noted. Hot sterilization is therefore im- 
practical because of heat damage to the mouthpiece as- 
semblies. Gas sterilization may not be feasible since 
special piping, venting, and other provisions are required. 



CONCLUSIONS 



Based on this review of available information, the ap- 
proach at the Bureau in the future will be to use a thor- 
ough cleaning process followed by immersion in a bleach- 
water solution for disinfecting SCSR mouthpieces. This 
form of cleaning and disinfection is not expensive. This 
recommendation is based upon the results of microbial 
testing and similar procedures advocated for disinfecting 
CPR and scuba training equipment. These procedures are 
thought to be effective in abating the spread of infectious 
disease. 

Chemical cold sterilants, which are not prohibitively 
expensive, could also be used. With respect to SCSR 
mouthpiece assemblies, microbial test results indicate that 



there is no advantage for sterilization over disinfection. At 
the same time, chemical sterilants are not readily available 
and must be purchased from medical supply houses. Ulti- 
mately, the trainer must decide if individual mouthpieces 
will be used or if mouthpieces will be shared by trainees. 
This decision will dictate the type of cleaning and/or dis- 
infection routine that will be used. 

It is hoped that this report will provide mine trainers 
and others with useful information for adequately cleaning 
and disinfecting SCSR mouthpieces to aid in preventing 
the spread of infectious disease during hands-on SCSR 
training. 



REFERENCES 



1. Federal Register. U.S. Mine Safety and Health Administration 
(Dep. Labor). Underground Coal Mining; Self-Contained Self-Rescue 
Devices: Emergency Temporary Standard and Proposed Rule. V. 52, 
No. 125, June 30, 1987, pp. 24374-24380. 

2. Vaught, C, M. J. Brnich, and H. J. Kellner. Effect of Training 
Strategy on Self-Contained Self-Rescuer Donning Performance. Paper 
in Mine Safety Education and Training Seminar. Proceedings: Bureau 
of Mines Technology Transfer Seminar, Pittsburgh, PA, May 17, 1988; 
Beckley, WV, May 19, 1988; St. Louis, MO, May 24, 1988; and Reno, 
NV, May 26, 1988. BuMines IC 9185, 1988, pp. 2-14. 

3. Favero, Martin S. Sterilization, Disinfection, and Antisepsis in 
the Hospital. Ch. in Manual of Clinical Microbiology, ed. by E. H. 
Lennette, A. Balows, W. J. Hausler, Jr., and H. J. Shadomy. Am. Soc. 
Microbiol., 4th ed., 1985, pp. 129-137. 

4. American Dental Association (Chicago, IL). Facts About AIDS 
for Dental Professionals. ADA, Nov. 1985, 8 pp. 



5. Centers for Disease Control (Atlanta, GA). Preventing the 
Transmission of Hepatitis B, AIDS, and Herpes in Dentistry. CDC 00- 
4846, 1985, 13 pp. 

6. American Heart Association. Standards and Guidelines for 
Cardiopulmonary Resuscitation and Emergency Cardiac Care: Safety 
in Training for and Providing CPR JAMA, v. 255, No. 21, 1986, 
pp. 2926-2928. 

7. Skirtich, Sharon (Am. Red Cross). General communication 
regarding cleaning procedure for CPR manikins, June 1986; available 
upon request from S. Skirtich, ARC, Pittsburgh-Allegheny County 
Chapter, Pittsburgh, PA. 

8. Bond, Walter W. Disinfection of Scuba Diving Equipment. 
JAMA, v. 258, No. 23, 1987, p. 3439. 



1NT.BU.OF MINES,PG1I.,PA 29050 



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